Female Pelvic Organ Prolapse The uterus, bladder, and rectum are all located around the vaginal canal. Because of the way these organs are arranged, it is possible for them to herniate or bulge into the vaginal canal when supportive tissues in the pelvic region become weak. Such bulges are called prolapses. Prolapse can lead to discomfort and heaviness in the vagina, difficulties using the toilet or the unwanted leakage of urine, called urinary incontinence. When a prolapse is large, tissue may even be seen hanging outside the vagina. Prolapse can be brought on by:

• Childbirth – May injure supportive structures in the pelvis. • Chronic coughing, chronic constipation, and heavy lifting – May cause straining of the

abdominal muscles. • Menopause - Causes estrogen levels to decrease. This drop in estrogen can cause pelvic

tissues to weaken. • Obesity • Normal aging

Symptoms of Prolapse Although your symptoms may differ slightly, you may notice any of the following with a prolapse -

• A bulge in your vagina that ranges in size from quite small to very large • Discomfort or pressure in your pelvis or vagina • Difficulty having a bowel movement • Trouble emptying your bladder • Pain with intercourse • Lower back pain • Increased discomfort with long periods of standing • Improved discomfort with lying down

Main types of prolapse

• Normal anatomy: As you can see the bladder, urethra, rectum and small bowel are located near the vaginal canal.

• Cystourethrocele: When the wall between the bladder and vagina weakens, the bladder can fall down into the vaginal cavity.

• Uterine Prolapse: The uterine wall can also slide down into the vagina. • Rectocele: Sometimes part of the rectal wall may protrude into the vagina. • Enterocele: Small bowel may also herniate into the vaginal wall. This usually occurs in

women who have had a hysterectomy.

Prolapse Treatment Options • Avoid constipation and straining during bowel movements.

• Use Kegel exercises to strengthen the muscles that support the pelvic organs. • Use biofeedback therapy to retrain your pelvic muscles. • Wear a pessary inside the vaginal canal to support the prolapsed tissue. • Add a hormone replacement therapy (HRT) medication or topical cream. • Surgery can restore your prolapsed pelvic tissues to their normal position.

Kegel Exercises Why do Kegels? Kegel exercises help to strengthen the muscles that support the vagina, uterus, bladder, and rectum. Greater support can be helpful in several ways:

• Prolapse may disappear or be less pronounced. • Kegels can help improve stress incontinence, the unwanted leakage of urine that occurs

with coughing, sneezing, lifting, and standing. • Sexual enjoyment may increase. • Pregnancy may be easier.

How are Kegels done? 1. First, locate your pubococcygeus (PC) muscle in your pelvic floor.

• Do this by trying to stop the flow of urine when you urinate. If you can successfully stop the flow, then you have correctly located your PC muscle.

• Alternatively, you can learn to exercise your PC muscle by: o Women - inserting two fingers in your vagina and tightening your vaginal

muscles around your fingers. o Men - tightening the muscles at the base of the penis or tightening your anal

sphincter around a finger. • If you cannot locate your PC muscle, our urology care team at the University of Chicago

Hospitals can help you begin a Kegel exercise routine. During a visit, we can talk about your Kegel technique, help you locate your PC muscle or even begin a biofeedback therapy program geared toward helping you find and exercise this muscle.

2. Once you have found your PC muscle:

• Squeeze your PC muscles for 5 seconds • Then relax for 5 seconds • Do 10 sets of squeezing, then relaxing. • Repeat these sets 15 times each day.

3. Remember to keep your abdominal muscles relaxed while you exercise your PC muscle. The best way to do this is to breathe normally while doing Kegels. Biofeedback Therapy What is biofeedback therapy?

Biofeedback is a learning process where you become more aware of and more able to control your own body’s functioning. In urology and gynecology, biofeedback is typically used to help patients locate and strengthen their pelvic floor pubococcygeus (PC) muscle. How does biofeedback work? During biofeedback therapy, special measuring devices are placed in your vagina, rectum or on your skin to monitor your pelvic floor. You are then asked to contract your PC muscle while watching the strength of each contraction on a computer screen. This interactive approach allows you to adjust each squeeze to make it stronger and more effective.

In the above example, the patient is learning to contract her pelvic floor muscles with more strength each time. She is also learning how to breathe properly and relax her abdominal muscles while exercising. Pubococcygeus (PC) Muscle This important muscular sheet helps anchor the urethra, vagina, anus and rectum in their proper anatomic locations. When the PC muscle weakens, these structures are more likely to shift out of place and prolapses may occur in women or urinary incontinence may occur in either sex.

Pessaries What is a pessary? A pessary is a ring-like device that can be placed in the vagina to support structures such as the uterus or bladder. Some women find that wearing a pessary can help alleviate the discomfort caused by pelvic organ prolapse. They may also find that they have better bladder control and less urinary incontinence. A urologist can almost always fit a patient with a pessary in one office visit. Pessaries come in various sizes, so it is important to find one that provides good support but also feels comfortable to the patient. Once a month, our patients at the University of Chicago Hospitals either remove their pessaries themselves or have their pessary removed in the office. The pessary is then thoroughly cleaned and reinserted. The picture below shows a common type of ring pessary. Pessaries usually cause very few problems, but an increased chance for developing vaginal irritation or infection does exist. Hormone Replacement Therapy (HRT) So far, the oral estrogen in HRT has not been reliably shown to provide relief to those suffering from pelvic organ prolapse and urinary incontinence. For this reason, and because oral estrogen has so many potential side effects, we do not recommend starting HRT for the sole purpose of treating these conditions. However, evidence has clearly demonstrated that estrogen can make skin thicker, softer, and smoother. It can also “plump up” the pelvic floor tissues and help women sustain their vaginal moistness. For this reason, it may be worthwhile to try a topical vaginal cream containing estrogen in the vaginal area. Prolapse Surgery at the University of Chicago Hospitals Section of Urology The decision to have prolapse surgery is an important one that should be made only after receiving all the options and facts from your physician. Ultimately, it is up to you to decide when your quality of life could be improved with surgery.